Impact of an Innovative Interdisciplinary Conference

Journal of Medical Education and Training

Research Article Open Access

Keywords: Interdisciplinary Conference; Gastroenterology Impact of an Innovative Fellowship Training; Medical Education; Image Recognition Interdisciplinary Conference Introduction Focused on High-Yield Images: Image recognition is an important skill for all gastroenterologists, particularly trainees. To diagnose most gastrointestinal and liver Significant Improvement in diseases, a combination of endoscopic, pathologic and radiologic Image Recognition Skills with knowledge is usually required. The American Gastroenterological Association’s (AGA) Core Curriculum has required training for all Gastroenterology, Radiology Gastroenterology Fellows in both Radiology and Pathology [1]. Specifically, in the section on the training of gastroenterologists in and Pathology Faculty Radiology, the Core Curriculum recommends that “trainees must have exposure at regular conferences that include radiographic Collaboration imaging studies in relation to gastrointestinal disease.” For Pathology, it advises that multidisciplinary conferences of gastroenterologists Pichamol Jirapinyo1,2*, Linda S. Lee1,2, Raquel O. Alencar3,2, and pathologists should be organized on a weekly or every other 4,2 3,2 4,2 Elizabeth Rinehart , Daniel A. T. Souza , Odise Cenaj , week basis to review specimens. In addition, the Core Curriculum Jerrold R. Turner4,2, Stephen Pelletier2, Molly L. Perencevich1,2, encourages assessment of knowledge in radiology and pathology. Helen M. Shields1,2 While single focused conferences in radiology or pathology are 1 Division of Gastroenterology, Hepatology and Endoscopy, Department of frequently included in the gastrointestinal (GI) fellows’ curriculum at Medicine, Brigham and Women’s Hospital, Boston, MA, USA individual programs and are an integral part of the fellowship training 2Harvard Medical School, Boston, MA, USA experience, either as a four week block or ongoing weekly established 3Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA conferences, at our GI fellowship program, we did not have specific 4Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA radiology and pathology conferences before this interdisciplinary conference was started in 2016. We are unaware of another *Corresponding author: Pichamol Jirapinyo, Email: [email protected] Gastroenterology program that has developed a specific conference to Received: 04 April 2020; Accepted: 12 May 2020; Published: 15 May 2020 help GI fellows recognize, not only GI endoscopy images, but also in the same conference receive training in the recognition of high-yield Abstract radiologic and pathologic images. Background: An innovative interdisciplinary conference focused It has been shown that learning in clinical settings alone is sometimes on recognition of high-yield images was established by faculty inadequate for trainees to acquire sufficient expertise. Previous studies from the Gastroenterology Division and Pathology and Radiology have explored the effect of additional educational offerings outside the Departments. clinical settings to augment this knowledge. For example, other groups have pioneered standardized educational programs to improve the Objective: To assess the effectiveness of the interdisciplinary endoscopic detection of early gastrointestinal cancers. The Asian Novel conference in improving image recognition skills. Imaging and Intervention Group organized a conventional classroom Methods: A prospective observational study. Primary Outcome: style program from November 2013 to March 2016 with a total of 41 Anonymous surveys assessed the effectiveness of the conference in workshops held in 13 different cities and countries in Asia. They were improving the perception of image recognition. Secondary Outcome: able to show a significant improvement in the post-test results compared Anonymous pre- and post-test scores assessed objective image to pre-test results for diagnosis of early esophageal neoplasia, early recognition. Statistics: A Likert scale was used to assess perceived gastric neoplasia and early colorectal neoplasia (p<0.0001) [2]. An improvement in image recognition. A paired Student’s t-test and a Chi- E-learning system was also used to improve the endoscopic diagnosis squared test were used to compare pre- and post-test scores and Likert of early gastric cancer worldwide. These investigators designed and scale scores, respectively. developed an international, randomized, controlled trial to evaluate the effectiveness of the E-learning system using video lectures and Results: Ten conferences were given between 2016 and 2018. self-exercise tests to gain experience in image recognition versus a A total of 51 out of 70 (72.9%) surveys were returned. 98% of the control group who did not receive E-Learning and showed that it led participants perceived the conference as “Extremely helpful” (59%) to a significant improvement (p<0.001) [3]. In addition to the benefits or “Very helpful” (39%) to their image recognition. Prior to the of teaching outside the clinical settings, prior studies have shown the conference, their comfort level with the subject matter was “Somewhat effectiveness of an interdisciplinary approach for teaching in various Comfortable” (comfort score of 2.5 ± 1.1). After the conference, their disciplines, such as Internal Medicine, Family Medicine, Mental Health comfort level increased to being “Very Comfortable” (comfort score Diseases and Medical Simulation [4-10]. of 4.0 ± 0.7) (p<0.0001). Participants’ surveys indicated a trend for the knowledge in the non-GI disciplines to improve the most (Pathology In this article, we describe a novel interdisciplinary conference 55%, Radiology 49%, Endoscopy 33%, p=0.08). At the beginning of created for gastroenterology fellows using faculty in endoscopy, the academic years, the average pre-test score on image recognition radiology and pathology. We then conducted a prospective study of GI skills of the gastroenterology fellows was 57% ± 19%. At the end of fellows to evaluate the effectiveness of this newly created conference at the academic year, the post-test score on the same images improved to improving self-reported image recognition skills and objective image- 70% ± 7% (p=0.0004). based pre- and post-test scores given at the beginning and at the end of Conclusion: An innovative, collaborative conference developed each academic year. by faculty experts in multiple disciplines focusing on high-yield endoscopic, pathologic and radiologic images was effective at improving objective and subjective image recognition skills. Copyright © 2020 The Authors. Published by Scientific Open Access Journals LLC. Jirapinyo P, et al. Volume 4, Issue 1 J Medic Educ Training 2020; 4:048

Methods Outcomes Study Design The primary outcome was the effectiveness of the conference in improving confidence in image recognition skills as assessed by The study was a prospective observational study conducted at anonymous paper surveys using a 5-point Likert scale (Appendix 1). an academic tertiary care center from September 2016 to May 2018. These surveys were given out at the beginning and collected at the end Interdisciplinary conference participants included gastroenterology of each conference from all participants including gastroenterology, (GI) fellows, GI pathology fellows, radiology residents and abdominal radiology and pathology residents and fellows. imaging and interventional radiology fellows. Attendance was voluntary. As each participant entered the conference, they were given The secondary outcome was fellows’ subjective perception of the Immediate Feedback Assessment Technique (IF-AT) (Epstein their level of readiness for the GI Training Examination (GTE) and the Educational Enterprises, Cincinnati, Ohio) card (Figure 1) [11]. Pre- and ABIM GI Board Examination. Subjective feedback on how to improve post-conference self-assessment tests were conducted on the subject of the conference was also collected, analyzed and used to improve the individual conference. An anonymous paper survey assessing the subsequent conferences (Appendix 1) Additionally, for only GI fellows, effectiveness of the conference and the quality of teaching was given to a cumulative image recognition test was administered at the beginning each participant at the end of each conference. of the academic year (2016-2017 and 2017-2018) and was compared to the scores at the end of the year (Appendix 2 and Appendix 3). These Gastroenterology fellows were invited to take an additional tests were given to all 14 general GI fellows at our institution during cumulative image recognition testing at the beginning and at the end each of the two consecutive years when the study was conducted. of the academic years 2016-2017 and 2017-2018. These tests focused on testing the knowledge on high-yield endoscopic, pathologic and Statistical Analysis radiologic images. All participants were given a random number in Perception of comfort with image recognition was assessed using order to keep the pre- and post-test results anonymous and assessed an anonymous paper survey with a Likert scale from 1 to 5 with 1 being for differences. The study was approved by the Partners Institutional “not at all comfortable” or “not at all helpful” and 5 being “extremely Review Board (IRB) in 2016. comfortable” or “extremely helpful.” The responses to this survey were Interdisciplinary Conferences with Faculty Collaboration analyzed using both a Student’s t-test and a Chi squared test where the Likert scores of 1-3 were grouped as “neutral/not comfortable” and The focus of the conferences during the academic year 2016-2017 Likert scores of 4-5 were grouped as “comfortable.” A paired Student’s was Gastrointestinal Cancers. For the academic year 2017-2018, the t-test was used to compare pre- and post- image recognition test scores. focus was Gastrointestinal Inflammation and/or Infection. Prior to A p-value less than 0.05 was deemed statistically significant. Statistical each conference, collaborative discussions among the faculty from the analysis was performed using Statistical Analysis Software version 9.4 three disciplines—Endoscopy, Radiology and Pathology—consistently (SAS Institute, Cary, NC). took place to ensure the highest quality images and teaching points. Endoscopic, radiologic and pathologic images of normal and diseased Results processes constituted the majority of each conference in addition A total of ten GI interdisciplinary conferences were given between to updated society guidelines and a brief discussion of practical September 2016 and May 2018. Conference topics are shown in management [12-15]. The conference took place every two months Table 1. A sample of high yield images from one of the conferences (8 weeks) and lasted 45 minutes. Faculty from all three disciplines on Barrett’s esophagus and esophageal adenocarcinoma is shown in participated in a collaborative format led by the moderator (P.J.). The Figure 2. The topics during the academic year 2016 to 2017 focused conferences were interactive with ongoing questions and answers from on GI malignancy, while those given during the academic year 2017 the participants throughout. In addition, each conference was begun to 2018 focused on GI infection and inflammation. Two of the five with a fun 5-minute self-assessment quiz of 3-5 case-based high-yield topics from the academic year 2016 to 2017 with the highest evaluation images reflecting specialty Board type questions using IF-AT (Epstein scores (Pancreatic Cystic Neoplasms and Choledochal Cysts and their Educational Enterprises) (Figure 1) [11]. These same images were Malignant Potential) were updated and given again during the academic shown and discussed during the conference and reviewed again at the year 2017 to 2018. end. On average, seven trainees (five GI fellows and two radiology/ pathology residents/fellows) attended each conference. Out of 70 given surveys, 51 were returned, with a response rate of 72.9%. Fifty of 51 participants (98%) perceived the conference as being “Extremely helpful” (59%) or “Very helpful” (39%) to their recognition of endoscopic, pathologic and radiologic images. Specifically, participants found the following features of the conferences to be the most helpful to their learning: an interdisciplinary approach with multiple faculty from different disciplines (39%), comparison of normal and abnormal pathologic images (14%), clear explanation with well-organized conference (14%), slide and image quality (10%), guideline update with management summary (8%), high-yield topics (6%), collegial environment (6%) and an interactive format (4%). Prior to the conference, participants’ comfort level with the subject matter was “Somewhat comfortable” (average comfort score of 2.5 ± 1.1 on a scale of 1 to 5 with 1 being “Not at all comfortable” and 5 being “Extremely comfortable”). After the conference, their comfort Figure 1: The Immediate Feedback Assessment Technique (IF-AT) level increased to being “Very comfortable” (average comfort score Scratch Card. Taken from Colbert J, Pelletier S, Xavier-Depina F, of 4.0 ± 0.7) (p<0.0001). When the Likert scores were grouped as Shields H. A pilot study of team learning on in-patient rounds. Clin “neutral/uncomfortable” and “comfortable,” 9 out of 51 trainees Teach. © 2015 John Wiley & Sons Ltd [11].

Table 1: Topics of the Gastroenterology Multidisciplinary Conference from Academic Years 2016-2017 and 2017-2018. Topics in Academic Year 2016-2017 Topics in Academic Year 2017-2018 Colon Polyp Syndromes Choledochal Cysts and Their Malignant Potential Barrett’s Esophagus and Esophageal Adenocarcinoma Infectious and Pill Esophagitis H. pylori Gastritis, MALT Lymphoma, Gastric Adenocarcinoma Small Bowel Diseases Pancreatic Cystic Neoplasms Microscopic Colitis Choledochal Cysts and Their Malignant Potential Pancreatic Cystic Neoplasms

(A) (B)

(C)

Figure 2: High-yield images from the Barrett’s esophagus and esophageal adenocarcinoma conference (A) Endoscopic images of Barrett’s esophagus using the Prague classification (B) Pathologic images of normal esophagus, esophagitis and Barrett’s esophagus with no dysplasia (C) Radiologic images of normal esophagus and esophageal adenocarcinoma with overlays. (Figure 2A taken from Sharma P, et al. Gastroenterology. 2006;31:1392-1399. Figure 2C taken from Carbo AR, et al. Pathology – Research and Practice. 2012;208:300-305).

Table 2: Anonymous Survey Questions and Responses for the Multidisciplinary Conference. Survey Questions Responses Extremely helpful 21/38 (55%) Very helpful 16/38 (42%) Was the conference helpful to your learning image recognition? Neutral 0/38 (0%) Somewhat helpful 1/38 (3%) Not at all 0/38 (0%) Not at all (1) 8/38 (21%) Somewhat comfortable (2) 11/38 (29%) How comfortable/confident were you with this subject matterbefore the lecture? Neutral (3) 16/38 (42%) Very comfortable (4) 3/38 (8%) Extremely comfortable (5) 0/38 (0%) Not at all (1) 0/38 (0%) Somewhat comfortable (2) 2/38 (5%) How comfortable/confident were you with this subject matterafter the lecture? Neutral (3) 4/38 (11%) Very comfortable (4) 26/38 (68%) Extremely comfortable (5) 6/38 (16%) Endoscopy 14/54 (26%) Which of your image recognition skills do you think was most improved? Pathology 22/54 (41%) Radiology 18/54 (33%)

(17.6%) reported feeling comfortable with the materials prior to prepared for the GTE and the ABIM GI Board Exam as a result of the conferences. This proportion of trainees who felt comfortable attending the lectures with 37% feeling “A lot more prepared” and 42% with the materials increased to 44 out of 51 trainees (86.3%) after feeling “Very prepared.” the conference (p<0.0001). Participants’ surveys indicated that At the beginning of the academic year, the GI fellows’ cumulative their knowledge of image recognition improved most in the area of image recognition pre-test score was 57 ± 19% (n=24). At the end of Pathology (55%), second in Radiology (49%), and third in Endoscopy the academic year, the cumulative image recognition post-test score (33%), although these differences did not reach statistical significance on the identical images improved to 70 ± 7% (n=20) (p = 0.0004). The (p=0.08) (Table 2). improvement in cumulative image recognition test scores persisted Seventy-nine percent of the GI fellow participants felt more when a subgroup analysis was performed by each academic year.

Specifically, for academic year 2016-2017, the scores improved from about what they are doing” [25]. This approach focuses on developing 49 ± 14% (n=10) prior to the first conference to 67 ± 8% (n=10) after students’ skills rather than on transmitting information. According to the last conference (p=0.01). For academic year 2017-2018, the scores the constructivist learning theory, “individuals learn through building increased from 67 ± 20% (n=14) prior to the first conference to 74 ± 7% their own knowledge, connecting new ideas and experiences to existing after the last conference (n=10) (p=0.04). knowledge and experiences to form new or enhanced understanding” [26]. Several techniques were used during our conferences to promote Discussion active learning including the IF-AT card to promote self-assessment This study proposes a novel method for teaching gastroenterology about the subject, adequate time to allow participants to synthesize fellows using an interdisciplinary approach and faculty collaboration. information and ask questions of the faculty. In addition, the round robin Faculty in three different areas, Gastroenterology, Radiology and question-and-answer technique was used throughout the conferences Pathology collaborated to create optimal organ- and disease-based to encourage participation in addition to the case-based learning conferences focused on high-yield endoscopic, radiologic and format. In 2014, Freeman and colleagues conducted a meta-analysis pathologic images for board preparation and consultative practice. demonstrating that compared to traditional lectures, courses with some Our study demonstrates that this interdisciplinary method of teaching active learning components were associated with increased student improves both Gastroenterology fellows’ comfort level and objective performance on exams, concept inventories and other assessments knowledge at diagnosing key gastrointestinal cancers and inflammatory with weighted standardized mean difference of 0.47 (p < 0.001). These diseases. Additionally, we noted a trend towards improved image results were consistent across disciplines [27]. Recently, the flipped recognition skills in the area of Pathology following the conferences. classroom has also highlighted the enjoyment and effectiveness of students actively teaching each other in small groups [28]. Traditionally, training during GI fellowship consists of technical and cognitive training. The technical aspects of GI training usually take place Our interdisciplinary conferences have several strengths. First, the in the endoscopy suite and occasionally in the simulation laboratory. conferences stressed both concept learning and active learning/teaching In contrast, training on the cognitive aspects of gastroenterology methods. Second, the format of the conferences we created was simple occurs in a more varied setting, such as on-the-spot teaching during and easily reproducible across institutions. Third, the expert-driven in-patient consultations, faculty teaching during fellows’sub-specialty curricula were strategically designed to include high-yield topics clinic sessions. In addition, the Division of Gastroenterology provides that readily integrated and intertwined the three disciplines with high required grand rounds, journal clubs and didactic lectures. In this study, quality visuals. Fourth, we demonstrated that in addition to participants’ we propose an alternative method of providing cognitive training during subjective comfort level, their objective scores on a cumulative image the gastroenterology fellowship using a voluntary attendance conference recognition test improved. In this study, the post-test was given at the using an interdisciplinary collaborative approach of faculty in the three end of each academic year to the Gastroenterology fellows rather than major disciplines. In contrast to a multidisciplinary approach, where after each conference in order to assess knowledge retention. “knowledge is sequenced in a manner that allows students to experience The weakness of our study is that it was performed at a single related disciplinary contributions to a topic” [16], interdisciplinary institution with a limited number of participants. refers to “an integration of knowledge from multiple disciplines in pursuit of an outcome that is not possible from a single disciplinary Conclusion approach” [17,18]. In our conferences, the curricula were designed so In summary, an innovative, novel, interdisciplinary conference that each diagnosis required the knowledge from at least two of the with faculty collaboration across the three different disciplines of three disciplines—endoscopy, pathology or radiology—in order to gastroenterology, radiology and pathology resulted in significant encourage image recognition, integration and synthesis. Ivanitskaya et improvement in image-recognition skills both objectively and al. proposed that interdisciplinary curricula promote flexible thinking, subjectively. Our methods are readily translatable to all subspecialty enhanced cognitive skills, ability to synthesize information and medical and surgical fellowships where image recognition is of improved critical thinking [19]. Additionally, interdisciplinary courses paramount importance for both clinical care and Specialty Board appear to promote structural knowledge that leads to better and deeper preparation. The success of this interdisciplinary conference has led to analyses of the interdisciplinary problem and topic, which may lead to our Division of Gastroenterology, Hepatology and Endoscopy to agree longer term memory [20,21]. to scale up this conference with an inter-disciplinary conference every Participants also rated having a comparison of normal and two weeks instead of every eight weeks beginning in the fall of 2020. abnormal images helpful to their learning. In 1967, Bruner et al. These more frequent conferences will focus on the interdisciplinary defined concept learning, also known as category learning, as “the approach to GI Trainees’ learning image recognition using endoscopy, search for and listing of attributes that can be used to distinguish radiology and pathology images as well as an in-depth discussion of exemplars from non-exemplars of various categories” [22]. While there specific topics. are many methods of learning a concept, exemplars comparison and contrast has been proposed as an efficient way to learn [23]. Comparing Acknowledgement different examples from the same category allows learners to exemplify We would like to thank our following radiology consultants (in variability within the category. On the other hand, contrasting two alphabetical order): Dr. Alan Cubre, Dr. Leslie Lee, Dr. Nisha Sainani, examples from different categories may allow learners to identify Dr. Julia Seol, Dr. Sree Tirumani. Additionally, we would like to thank attributes within each example with diagnostic value [24]. Applying Dr. Kitt Shaffer, Vice Chair of Education Department of Radiology and this theory, our conferences were designed so that several images from Professor of Radiology of Boston University School of Medicine for the same category, such as different radiologic images of choledochal her overlays on Figure 2. cysts, and several images from different categories, such as pathologic images of normal esophagus, Barrett’s esophagus without and with Ethical statement dysplasia, were used as teaching exemplars (Figure 2). This study was presented as a poster abstract at the Brigham and In our study, participants rated the interactive format with a Women’s Hospital’s Medical Education Day in April 2018 in Boston, collaborative environment of multi-specialty faculty as useful to M.A. and at Digestive Diseases Week in June 2018 in Washington, D.C. their learning. In 1991, Bonwell and Elson defined active learning as This material has not been published in whole or in part elsewhere. “instructional activities involving students in doing things and thinking Additionally, the manuscript is not currently being considered for

Citation: Jirapinyo P, Lee LS, Alencar RO, et al. Impact of an Innovative Interdisciplinary Conference Focused on High-Yield Images: Significant Improvement in Image Recognition Skills with Gastroenterology, Radiology and Pathology Faculty Collaboration. J Medic Educ Training 2020; 4:048 Jirapinyo P, et al. Volume 4, Issue 1 J Medic Educ Training 2020; 4:048 publication in another journal. All authors have been personally and 13. Elta GH, Enestvedt BK, Sauer BG, Lennon AM. ACG Clinical Guideline: actively involved in substantive work leading to the manuscript. Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol. 2018; 113:464-479. References 14. Vege SS, Ziring B, Jain R, Moayyedi P, Clinical Guidelines Committee; 1. American Association for the Study of Liver Diseases, American College American Gastroenterology Association. 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1. Appendix 1 Sample Anonymous Survey Given the End of Each Conference.

Appendix 2 Question 1

• A 65 year old construction worker has the polyp below removed from his ascending colon. Based on the histology, what type of polyp is this?

A) Hyperplastic polyp B) Sessile serrated adenoma C) Juvenile polyp D) Adenoma with dysplasia

Question 2

• This 4 cm lesion is found at the splenic flexure in a 55 year old woman on a screening colonoscopy. Biopsies show that the lesion is a villous adenoma. What is the chance of malignancy?

A) 20% B) 40% C) 60% D) 80%

Question 3

• This desmoid lesion is seen on an abdominal/pelvic CT scan of a 35 year old woman with a history of colon cancer. Which polyp syndrome is a desmoid tumor associated with?

A) Gardner’s syndrome B) HNPCC C) Juvenile polyposis syndrome D) Peutz-Jeghers syndrome

Question 4

• A 47 year old man who is a heavy smoker has a long history of severe acid reflux. Recent esophageal biopsies showed an abnormality (see arrow) that is most compatible with which of the following diagnoses?

A) Barrett’s esophagus B) Barrett’s esophagus with dysplasia C) Adenocarcinoma D) Squamous cell carcinoma

Question 5

• Here is an endoscopic finding of a 45 year old man with a long history of acid reflux. What is the Prague staging of this Barrett’s esophagus?

36 cm

A) C31M29 B) C7M2 C) C5M2 31 cm D) C5M7

29 cm

Question 6

• A 46 year old woman complains of worsening dysphagia to both solids and liquids for the past 5 years. Her barium study shows the following image. What is the most likely cause of this finding?

A) Failed LES relaxation B) Malignancy C) Esophageal spasm D) Stricture

Question 7 • A 42 year old woman from Moscow presents with epigastric pain over the past year. Biopsy of her stomach is looked at by routine H&E and immunohistochemistry. What abnormality is seen on the top of the gastric mucosal cells?

A) Schistosomiasis B) Ascaris C) Hookworm D) H. pylori

Question 8

• A 72 year old woman who was found on a CT scan to have large ovarian masses presents with early satiety and weight loss for 3 months. An endoscopy shows a non-distentable stomach with large heaped-up submucosal masses. What is this endoscopic finding most likely due to?

A) NSAIDs-induced peptic ulcer B) H. pylori gastritis C) Leiomyosarcoma D) Signet ring adenocarcinoma

Question 9

• A 52 year old woman with history of breast cancer who presents with few month history of early satiety and weight loss. CT abdomen shows the following finding. What is the most likely diagnosis?

A) Liver metastases causing external compression of the stomach B) Linitis plastica C) Gastritis D) Foreign body ingestion

Question 10

• 74 year old female with jaundice and weight loss. enzymes. What is the diagnosis?

A) Pancreatic neuroendocrine tumor B) Pancreatic adenocarcinoma C) Metastatic colonic adenocarcinoma D) Intraductal Papillary Mucinous Neoplasm

Question 10

• 74 year old female with jaundice and weight loss. enzymes. What is the diagnosis?

A) Pancreatic neuroendocrine tumor B) Pancreatic adenocarcinoma C) Metastatic colonic adenocarcinoma D) Intraductal Papillary Mucinous Neoplasm

Question 10

• 74 year old female with jaundice and weight loss. enzymes. What is the diagnosis?

A) Pancreatic neuroendocrine tumor B) Pancreatic adenocarcinoma C) Metastatic colonic adenocarcinoma D) Intraductal Papillary Mucinous Neoplasm

Question 11

• A 73 year old woman with a history of epigastric pain and anorexia. What does this endoscopic finding suggest?

A) Ampulla adenoma B) Biliary stone C) Pancreatic duct stone D) Intraductal papillary mucinous neoplasm

Question 12

• The following incidental MRI finding is seen in a 42 year old man with no pertinent past medical history. What is the next best step?

A) Endoscopic ultrasound B) Surveillance MRI in 12 months C) Endoscopic or percutaneous drainage D) Surgical referral

Question 13

• 71 year old man with a solitary right hepatic lobe nodule (6 cm x 5 cm). What is the diagnosis?

A) Metastatic adenocarcinoma B) Hepatocellular carcinoma C) Hepatic Adenoma D) Focal Nodular Hyperplasia

Question 13

• 71 year old man with a solitary right hepatic lobe nodule (6 cm x 5 cm). What is the diagnosis?

A) Metastatic adenocarcinoma B) Hepatocellular carcinoma C) Hepatic Adenoma D) Focal Nodular Hyperplasia

Question 13

• 71 year old man with a solitary right hepatic lobe nodule (6 cm x 5 cm). What is the diagnosis?

A) Metastatic adenocarcinoma B) Hepatocellular carcinoma C) Hepatic Adenoma D) Focal Nodular Hyperplasia

Question 14

• A 23 year old Asian American woman with no other past medical history presents with recurrent pancreatitis. Fluoroscopic examination is shown here. What is the recommended management?

A) Bile duct cyst excision + CCY B) Bile duct cyst excision + CCY + hepatectomy C) Sphincterotomy D) Liver transplantation

Question 15

• A 42 year old man with history of hemochromatosis underwent surveillance MRI of the liver. What is the risk for HCC?

A) 5% B) 10% C) 20% D) 30%

Appendix 3 Question 1

• A 35 year old woman presents with right upper quadrant pain. Labs are notable for AST/ALT 582/756, Tbili/Dbili 2.4/1.7. RUQ ultrasound is normal. Endoscopy shows the following. What is the diagnosis?

A) Choledochal cyst I B) Choledochal cyst III C) Choledochal cyst V D) Intraductal papillary mucinous neoplasm

Question 2

• A 67 year old woman presents with recurrent cholangitis. MRCP shows the following. What malignancy is she at the highest risk for?

A) Gallbladder adenocarcinoma B) Cholangiocarcinoma C) Hepatocellular carcinoma D) Pancreatic adenocarcinoma

Question 3

• An 80 year old man with a history of choledochal cyst I presents with jaundice and weight loss. EUS and FNB of the cyst yield the following. What is the diagnosis?

A) Gallbladder adenocarcinoma B) Cholangiocarcinoma C) Hepatocellular carcinoma D) Pancreatic adenocarcinoma

Question 4

• A 37 year old man with a history of squamous cell lung cancer (on chemotherapy) complains of odynophagia. Endoscopy shows the following. What is the likely diagnosis?

A) Candida esophagitis B) Herpes simplex esophagitis C) CMV esophagitis D) Radiation-induced esophagitis

Question 5

• A 45 year old man with a history of HIV presents with odynophagia. Biopsies of the esophageal lesions show the following. What is the diagnosis?

A) Candida esophagitis B) HSV esophagitis C) CMV esophagitis D) Pill esophagitis

Question 6

• A 65 year old man with a long history of acid reflux presents with worsening of his reflux symptoms despite PPI. CT scan shows the following. What is the likely diagnosis?

A) Achalasia B) Esophagitis C) Esophageal spasm D) Stricture

Question 7

• A 40 year old woman with history of rheumatoid arthritis presents with diarrhea. Labs are notable for iron deficiency anemia. Endoscopy shows the following. What is the possible diagnosis?

A) Crohn’s disease B) Celiac disease C) Ulcerative colitis D) H. pylori

Question 8

• The same patient undergoes biopsies of the duodenum, which shows the following. What is the diagnosis?

A) Crohn’s disease B) Celiac disease C) Ulcerative colitis D) H. pylori

Question 9

• A 62 year old man with a history of refractory sprue who presents with 25 pound weight loss. CT scan shows the following. What is the possible diagnosis?

A) Enteropathy-associated T-cell lymphoma B) Small bowel adenocarcinoma C) Leiomyosarcoma D) Gastrointestinal stromal tumors

Question 10

• A 65 year old woman presents with watery diarrhea and bloating. Colonoscopy shows the following. What is the possible diagnosis?

A) Microscopic collitis B) Ulcerative colitis C) Crohn’s disease D) Clostridium difficile colitis

Question 11

• The same patient undergoes random colonic biopsies, which show the following. What is the diagnosis?

A) Collagenous colitis B) Lymphocytic colitis C) Ulcerative colitis D) Crohn’s disease

Question 12

• A 33 year old woman presents with a 10 day history of RLQ severe crampy pain, bloating, nausea, vomiting and decreased stool output.

What is the likely diagnosis?

A) Collagenous colitis B) Lymphocitic colitis C) Ulcerative colitis D) Crohn’s disease

Question 13

• A 73 year old woman with a history of epigastric pain and anorexia. What does this endoscopic finding suggest?

A) Ampulla adenoma B) Biliary stone C) Pancreatic duct stone D) Intraductal papillary mucinous neoplasm

Question 14

• 45 year old woman is found incidentally to have the following finding. What is the possible diagnosis?

A) Intraductal papillary mucinous neoplasms B) Serous cystadenoma C) Mucinous cystic neoplasm D) Pancreatic adenocarcinoma

Question 15

• The same patient underwent a surgical resection of the lesion. Pathology shows the following. What is the diagnosis?

A) Intraductal papillary mucinous neoplasms B) Serous cystadenoma C) Mucinous cystic neoplasm D) Pancreatic adenocarcinoma